F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect,
exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident
property, are reported immediately for 1 of 3 residents (Resident #1) reviewed for neglect, in that:
The facility failed to report the allegation of neglect for Resident #1 to the State Agency within required
reporting timeframes.
This failure placed residents at risk ongoing neglect.
Findings included:
Record review of Resident #1 revealed a [AGE] year-old male admitted to the facility on [DATE] and
readmitted on [DATE] with a diagnosis of Acute Hairline Fracture at Distal radius epi Metaphysis of Left
Wrist (Bone Fracture and injury to the growth plate at the wrist end of the radius bone on the forearm);
Acute Hairline Fracture at Ulnar Styloid Process (a break in the bony part of the wrist at the end of the
ulna(a long bone in the forearm that runs from the elbow to the wrist on the same side the little finger), next
to the pinky finger): Peripheral (Vascular) Disease (a circulatory condition in which narrowed blood vessels
reduce blood flow to the limbs), Atherosclerosis of Native Arteries of Extremities with Rest Pain, Right Leg
(a disease that causes the arteries in the legs and feet to narrow and harden, reducing blood flow).
Record review of Resident #1's MDS (Minimum Data Sheet) dated 02/20/2024 revealed Resident #1 BIMS
(Brief Interview for Mental Status) score was noted to be 05/15 indicating severe cognitive impairment.
Resident #1 required modified to total assistance making decisions regarding tasks and providing daily
care.
Record review or the Provider Investigation Report dated 04/22/2024 indicated an allegation of neglect was
reported to the state agency on 4/30/2024 regarding Resident #1 which was past the two hours required to
submit an incident of alleged neglect. The cover sheet was addressed to the DADS Consumer Rights and
Services agency. The incident occurred on 04/17/2024 at 3:44 p.m.
The incident involved Resident #1's left hand and wrist, which was stuck in the wheel of his wheelchair,
which resulted in a fracture.
On 05/16/2024 at 3:45 p.m. interviewed the administrator, revealed that he was responsible for sending the
reports to the CII provider number. The Administrator revealed that he may have sent the
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
455835
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Interlochen Health and Rehabilitation Center
2645 West Randol Mill Rd
Arlington, TX 76012
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provider Investigation Report to the wrong number. The Administrator did not have proof that he sent the
Provider Investigation Report to the wrong number. The Administrator revealed that he must have forgot to
send to the CII provider immediately after incident occurred.
Record review of the facility's Abuse policy revised 03/29/2028 revealed in part: .it is the policy of the center
to take appropriate steps to prevent the occurrence of abuse, neglect .injuries of unknown origin .and to
ensure that all alleged violations .are reported immediately to the Administrator, DON and/or Abuse
Prevention Coordinator .will also be reported to the HHSC .
Review of Provider Letter PL 19-17, issued 07/10/19, revealed, .required reporting timeframes .neglect,
exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident
property, that results in serious bodily
injury .immediately, but not later than two hours after the incident occurs or is suspected .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455835
If continuation sheet
Page 2 of 2
